UPSC Medical Science 2025 — Paper II

The question demands a multi-part response with varying directives: 'briefly describe' for (a), 'discuss' for (b), and application-based responses for (c)-(e). Allocate approximately 20% time each to parts (a), (b), (d), and (e) given equal 10-mark weightage, with 15% to (c) which has slightly lower complexity. Structure as: brief introduction, then address each sub-part sequentially with clear sub-headings, ensuring clinical precision for pyelonephritis imaging, WHO ARI criteria specifics, SAM hypothermia protocols, and scabies mass drug administration strategies.

• (a) Lifestyle interventions for CAD: smoking cessation, DASH/Mediterranean diet, physical activity (150 min/week moderate intensity), weight management (BMI <25 kg/m²), stress reduction, diabetes and hypertension control
• (b) Imaging in pyelonephritis: CT (gold standard—striated nephrogram, wedge-shaped hypodensities), DMSA scan (cortical defects, gold standard for chronic), ultrasound (enlarged kidney, altered echogenicity, power Doppler for perfusion defects), IVU/CT urography for complications
• (c) WHO ARI criteria: fast breathing (RR >50/min if 2-12 months, >40/min if 1-5 years), chest indrawing, stridor, danger signs (unable to drink, convulsions, lethargy); treatment—home care for pneumonia, hospitalization with oxygen and antibiotics for severe pneumonia, referral for very severe disease
• (d) SAM hypothermia: treatment with warming room (32-34°C), skin-to-skin contact/Kangaroo mother care, warm IV fluids if needed; prevention with ambient temperature maintenance, immediate feeding, covering head, avoiding bathing, continuous monitoring
• (e) Scabies: Sarcoptes scabiei var. hominis; transmission via prolonged skin contact, shared bedding/clothing, asymptomatic carriers; treatment with 5% permethrin or oral ivermectin (200 mcg/kg), simultaneous treatment of all household contacts, washing clothes at 60°C, treating secondary infection

The directive 'outline' demands a systematic, stepwise presentation of diagnostic and management protocols. Structure: (a) DKA—20 marks—spend ~40% time/words on ABC approach, fluid resuscitation, insulin protocol, potassium management, and complication monitoring; (b) Diarrhoea—20 marks—~35% on definition (WHO criteria), aetiological classification (infectious vs non-infectious), dehydration assessment using IAP/IMNCI guidelines, nutritional management (BRAT diet continuation, zinc supplementation), and preventive strategies (ORS promotion, rotavirus vaccination under UIP); (c) Eczema—10 marks—~25% on definition (dermatitis), morphological classification (endogenous vs exogenous), and structured comparison table for contact dermatitis types. Use flowcharts for DKA management and dehydration assessment.

• (a) DKA: Recognition of triad (hyperglycaemia >250 mg/dL, ketonaemia, metabolic acidosis pH <7.3), immediate ABC stabilization, isotonic saline resuscitation (15-20 mL/kg in first hour), fixed-rate IV insulin (0.1 U/kg/hr) or weight-based protocol, potassium replacement protocol (maintain 4-5 mEq/L), bicarbonate controversy (avoid unless pH <6.9), and cerebral oedema monitoring
• (b)(i) Acute diarrhoea: WHO definition (<14 days duration, ≥3 loose stools/24h), causes—viral (rotavirus, norovirus), bacterial (ETEC, Shigella, Salmonella, V. cholerae), protozoal (Giardia, Entamoeba), and non-infectious (antibiotic-associated, lactose intolerance); dehydration assessment using IAP/IMNCI 4-point scale (none, some, severe, shock) with clinical markers (skin pinch, tears, mental status, radial pulse)
• (b)(ii) Nutritional management: continued feeding (breast milk/formula), energy-dense foods, zinc supplementation (10-20 mg/day for 10-14 days), avoidance of sugary drinks; prevention—exclusive breastfeeding 6 months, safe water/sanitation, handwashing, rotavirus vaccine (RVV) under India's UIP, typhoid conjugate vaccine, and ORS corner promotion
• (c)(i)-(ii) Eczema: Definition as inflammatory dermatosis with pruritus, erythema, and epidermal changes; classification into endogenous (atopic, seborrhoeic, nummular, dyshidrotic, lichen simplex chronicus) and exogenous (contact, photodermatitis, stasis)
• (c)(iii) Allergic vs irritant contact dermatitis: structured comparison—immunological mechanism (type IV delayed hypersensitivity vs direct cytotoxicity), dose-response (no threshold vs threshold-dependent), clinical pattern (well-demarcated, spreading beyond contact area vs confined to contact site), latency period (sensitization required vs immediate), and common examples (nickel, poison ivy vs detergents, acids)

The directive 'elaborate' in (a) demands comprehensive, detailed exposition with supporting evidence. Allocate approximately 50% of time/words to part (a) given its 25 marks, 30% to part (b) for 15 marks, and 20% to part (c) for 10 marks. Structure: begin with concise definitions, then systematically address each sub-part with clinical reasoning, evidence-based protocols, and prognostic considerations. Conclude with integrated take-home messages across the three clinical scenarios.

• (a)(i) Indications for antiviral therapy: HBeAg-positive/negative with elevated ALT (>2× ULN) and HBV DNA >20,000/2,000 IU/mL respectively; cirrhosis with detectable HBV DNA regardless of ALT; family history of HCC/cirrhosis; significant fibrosis (≥F2 by FibroScan/APRI)
• (a)(ii) First-line regimens: Tenofovir disoproxil fumarate (TDF) 300mg OD or Entecavir 0.5mg OD (naïve)/1mg OD (lamivudine-experienced); monitoring: HBV DNA q3-6mo, HBeAg/anti-HBe, ALT, creatinine/eGFR, phosphate (TDF), HBsAg loss annually; resistance testing if virologic breakthrough
• (b) RDS risk factors: prematurity (<34 weeks), maternal diabetes, elective C-section without antenatal steroids, male sex, perinatal asphyxia, second twin; Differential: TTN, sepsis/pneumonia, congenital heart disease (PDA/CHD), meconium aspiration, pulmonary hemorrhage; Management: CPAP, surfactant (poractant alfa 100mg/kg), ventilatory support, supportive care
• (c)(i) Diagnosis: Impetigo herpetiformis (pustular psoriasis of pregnancy) – characteristic flexural grouped pustules, fever, hypocalcemia risk; differentiate from acute generalized pustular psoriasis and pustular drug eruption
• (c)(ii) Management: Prompt delivery if near term; systemic corticosteroids (prednisolone 0.5-1mg/kg), cyclosporine as steroid-sparing; supportive care (fluids, electrolytes, calcium repletion); dermatology-obstetrics joint care
• (c)(iii) Complications: Maternal – hypocalcemia, sepsis, placental insufficiency, preterm labor; Fetal – IUGR, stillbirth, neonatal sepsis; recurrence risk in subsequent pregnancies

The directive 'differentiate' in part (a)(i) demands systematic comparison, while 'describe' in (a)(ii), 'enumerate/define/state' in (b), and 'discuss' in (c) require comprehensive coverage. Allocate approximately 50% time/words to part (a) given its 25 marks (10+15), with 30% to part (b) (15 marks) and 20% to part (c) (10 marks). Structure: begin with morphological differentiation of ALL vs AML using FAB/WHO criteria, followed by age-stratified ALL management protocols, then list UIP/NIS vaccines with AEFI definitions and specific examples (DPT, measles, OPV), concluding with renovascular hypertension diagnostic algorithm and revascularization strategies.

• Part (a)(i): Peripheral smear findings—ALL shows lymphoblasts (high N:C ratio, scant cytoplasm, no granules, TdT+); AML shows myeloblasts (Auer rods, myeloperoxidase+, Sudan black B+, CD13/CD33+); bone marrow blast threshold ≥20% for both; cytogenetic markers (Philadelphia chromosome in ALL, t(8;21), inv(16) in AML)
• Part (a)(ii): Pediatric ALL—risk-stratified therapy using NCI/CCLG criteria, 4-drug induction (vincristine, dexamethasone, L-asparaginase, doxorubicin), CNS prophylaxis, maintenance with 6-MP/MTX; Adult ALL—hyper-CVAD or pediatric-inspired regimens, allogeneic HSCT for high-risk/Ph+ (imatinib/ponatinib), blinatumomab/inotuzumab for refractory disease
• Part (b): NIS vaccines—BCG, OPV/IPV, Hepatitis B, DPT, Measles/MMR, JE, Rotavirus, PCV, Pentavalent; AEFI definition—any untoward medical occurrence post-immunization not necessarily causally related; specific AEFIs—DPT (sterile abscess, HHE, encephalopathy), Measles (febrile seizures, thrombocytopenia), OPV (VAPP)
• Part (c): Diagnostic approach—clinical clues (onset <30 or >55 years, abdominal bruit, flash pulmonary edema, resistant hypertension), screening with Doppler ultrasound, confirmatory CTA/MRA, gold-standard renal angiography; curative management—percutaneous transluminal renal angioplasty (PTRA) with stenting for fibromuscular dysplasia, surgical revascularization for atherosclerotic disease, ACE inhibitors with caution in bilateral disease

The directive 'discuss' demands a comprehensive, analytical treatment across all six sub-parts. Allocate time proportionally: ~20% each to (a), (b), (c) and (d) which carry 10 marks each, and ~10% each to (e) and the remaining balance. Structure with brief introductions for each sub-part, systematic enumeration for (a)(i) and (c)(i), descriptive detail for (a)(ii), (b), (d), and policy-analytical depth for (c)(ii) and (e). Conclude with integrated public health implications where relevant.

• (a)(i) Advantages of laparoscopic surgery: minimal access, reduced post-op pain, shorter hospital stay, cosmesis, reduced adhesion formation; Limitations: cost, steep learning curve, loss of tactile sensation, port-site metastasis, gas embolism risk
• (a)(ii) Pneumoperitoneum techniques: Veress needle (closed), Hasson open technique, direct trocar insertion, optical trocar; mention CO2 properties, pressure limits (12-15 mmHg), and complications
• (b) Anal fissure: aetiology (constipation, low-fibre diet, trauma, childbirth); clinical features (acute/chronic, sentinel pile, hypertrophied papilla, spasm); management (conservative: fibre, sitz bath, GTN/diltiazem ointment; surgical: lateral internal sphincterotomy, fissurectomy)
• (c)(i) MMR definition (maternal deaths per 100,000 live births); causes in India: haemorrhage, sepsis, hypertensive disorders, obstructed labour, abortion complications, anaemia; mention SRS and HMIS data
• (c)(ii) MMR reduction strategies: JSY/JSSK, institutional delivery promotion, EmOC training, SBA training, blood bank availability, PPIUCD, anaemia prophylaxis, community mobilization through ASHAs
• (d) Pelvic endometriosis: clinical features (dysmenorrhoea, dyspareunia, infertility, chronic pelvic pain); diagnosis (TVS, MRI, laparoscopy with staging per rASRM classification); treatment (medical: NSAIDs, COCs, GnRH agonists, LNG-IUD; surgical: laparoscopic excision/ablation, fertility preservation)
• (e) Kilkari initiative: mHealth voice messaging service under NHM/Ministry of Health; target: pregnant women, new mothers up to one year postpartum; implementation: 72 weekly timed calls on maternal-child health, nutrition, immunization, family planning; technology partner (BBC Media Action), integration with ANC/PNC services

The directive 'discuss' demands a comprehensive, analytical treatment with balanced coverage across all five sub-parts. Allocate approximately 40% of time/words to part (a) given its 20 marks, 30% to part (b) for 15 marks, and 30% to part (c) for 15 marks. Structure as: brief introduction → systematic coverage of (a)(i)-(iii) with emphasis on management protocols → (b) with clinical features, management and clear comparative table → (c) with HBNC objectives and ASHA responsibilities → concluding synthesis on integrated maternal-neonatal care.

• Part (a)(i): Classification per ISSHP/ACOG (Chronic hypertension, Gestational hypertension, Preeclampsia-eclampsia, Preeclampsia superimposed on chronic hypertension) with diagnostic criteria
• Part (a)(ii): Types of eclampsia (antepartum, intrapartum, postpartum) and complications (maternal: CVA, DIC, renal failure, hepatic rupture; fetal: IUGR, abruption, stillbirth)
• Part (a)(iii): Antepartum eclampsia management: ABCDE approach, MgSO4 regimen (Pritchard/Zuspan), control of severe hypertension (labetalol/hydralazine), delivery planning at 32 weeks with corticosteroids, monitoring for magnesium toxicity
• Part (b)(i)-(ii): UC clinical features (bloody diarrhea, tenesmus, continuous involvement, crypt abscesses), management (5-ASA, steroids, immunomodulators, surgery indications); UC vs Crohn's table (skip lesions, transmural, granulomas, fistulas, rectal sparing)
• Part (c): HBNC objectives (reduce NMR/IMR, early identification of danger signs, promote breastfeeding, thermal care); ASHA responsibilities (7 home visits, tracking LBW babies, referral for danger signs, counseling on exclusive breastfeeding, cord care, immunization)

The directive 'describe' demands systematic elaboration of clinical features, diagnostic pathways, and programmatic details. Allocate approximately 40% of time/words to part (a) peritonitis (20 marks), 30% to part (b) Anaemia Mukt Bharat (15 marks), and 30% to part (c) infertility and ART (15 marks). Structure: begin with (a)(i) clinical features and diagnostic workup in sequence, followed by (ii) management principles and (iii) complications; then (b) interventions, specific measures, and target groups; finally (c)(i) definition and tubal factor investigation, closing with (ii) ART enumeration. Use diagrams for peritonitis pathophysiology and infertility workup flowchart.

• (a)(i) Clinical features of peritonitis: acute abdomen with guarding, rigidity, rebound tenderness, absent bowel sounds, fever, tachycardia; diagnostic workup includes CBC, serum amylase, erect chest X-ray (free air under diaphragm), USG abdomen, diagnostic paracentesis (ascitic fluid analysis for PMN count, Gram stain, culture, amylase, bilirubin), and CT scan for localized collections
• (a)(ii) Principles of management: NPO, IV fluids, NG tube decompression, broad-spectrum antibiotics (covering Gram-negatives and anaerobes), source control (surgery for perforated viscus, abscess drainage), organ support, and nutritional support; mention sepsis protocol
• (a)(iii) Complications: septic shock, multi-organ dysfunction syndrome (MODS), intra-abdominal abscess, enterocutaneous fistula, adhesive intestinal obstruction, and death
• (b) Anaemia Mukt Bharat: six interventions—prophylactic iron-folic acid supplementation, deworming, intensified year-round behavioural change communication, testing and treatment of anaemia using digital methods, point-of-care treatment, and mandatory provision of fortified foods in ICDS and PM POSHAN; targets children 6-59 months, 5-9 years, 10-19 years, women of reproductive age, pregnant women, and lactating women
• (c)(i) Infertility definition: failure to conceive after 12 months of unprotected intercourse in women <35 years (6 months if ≥35); tubal factor investigation: HSG (hysterosalpingography), SIS (saline infusion sonography), laparoscopic chromopertubation, and hysterolaparoscopy as gold standard
• (c)(ii) ART procedures: IUI (intrauterine insemination), IVF (in vitro fertilization), ICSI (intracytoplasmic sperm injection), GIFT (gamete intrafallopian transfer), ZIFT (zygote intrafallopian transfer), TESA/PESA (sperm retrieval), cryopreservation, and preimplantation genetic testing

The directive 'describe' demands comprehensive, structured exposition of facts, mechanisms and procedures across all sub-parts. Allocate approximately 40% of time/words to part (a) given its 20 marks, 30% to part (b) with three sub-sections, and 30% to part (c). Structure as: brief introduction acknowledging India's malaria elimination timeline; systematic coverage of (a) targets, Category 3 interventions and surveillance parameters; (b) WHO MEC categories, IUCD complications with clinical correlates, and stepwise Cu-T management algorithm; (c) embryological basis with diagram, clinical features by cleft type, and multidisciplinary management principles; conclude with integrated public health perspective on reproductive and child health in India.

• Part (a): 2027 target (zero indigenous malaria in Category 1 states/UTs) and 2030 target (malaria-free India); Category 3 interventions include intensified IRS, LLIN distribution, ACT-AL/ACT-SP based treatment, radical cure with primaquine, and strengthened surveillance
• Part (a): Surveillance parameters include API, SPR, Pf proportion, therapeutic efficacy studies, insecticide resistance monitoring, and case-based reporting through IHIP
• Part (b)(i): WHO MEC categories 1-4 with examples (category 1: no restriction like COPD; category 4: unacceptable risk like breast cancer with Cu-IUCD; category 3: theoretical concerns like migraine with aura)
• Part (b)(ii): IUCD complications—immediate (pain, syncope, perforation), early (expulsion, PID, bleeding), late (pregnancy with device, embedment, actinomycosis)
• Part (b)(iii): Misplaced Cu-T management—confirm location by ultrasound/X-ray, remove if extrauterine or partially expelled, hysteroscopic removal if embedded, laparoscopic retrieval if perforated
• Part (c): Embryogenesis—failure of palatal shelves to fuse at 8-12 weeks due to genetic (IRF6, MSX1), environmental (smoking, folate deficiency), or mechanical factors; clinical features by Veau classification; principles of feeding, speech therapy, orthodontic preparation, and staged surgical repair (palatoplasty at 9-18 months)